Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries.

BACKGROUND: Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. METHODS: We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. RESULTS: We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. CONCLUSIONS: Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

Post-epidemic health system recovery: A comparative case study analysis of routine immunization programs in the Republics of Haiti and Liberia.

Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively. First, we triangulated data between the peer-reviewed and grey literature; in-depth key informant interviews with subject matter experts; and quantitative metrics of population health and health system functioning. We used these data to construct thick descriptive narratives for each case. Finally, we performed a cross-case comparison by applying a thematic matrix based on the Essential Public Health Services framework to each case narrative. In Liberia, post-Ebola routine immunization coverage surpassed pre-epidemic levels, a feat attributable to investments in surveillance, comprehensive risk communication, robust political support for and leadership around immunization, and strong public-sector recovery planning. Recovery efforts in Haiti were fragmented across a broad range of non-governmental agencies. Limitations in funding, workforce development, and community engagement further impeded vaccine uptake. Consequently, Haiti reported significant disparities in subnational immunization coverage following the epidemic. This study suggests that embedding in-country expertise within outbreak response structures, respecting governmental autonomy, aligning post-epidemic recovery plans and policies, and integrating outbreak response assets into robust systems of primary care contribute to higher, more equitable levels of routine immunization coverage in resource-constrained settings recovering from epidemics.

Effects of environmental impact and nutrition labelling on food purchasing: An experimental online supermarket study.

Nutrition labels and ecolabels can support consumers to make healthier and more sustainable choices, and the former is now widespread. But there is no information on the impact of ecolabels in the presence of nutrition labels. The aims of this study were primarily to examine whether (1) ecolabels are effective at promoting sustainable purchasing behaviour if presented alongside nutrition labels; (2) and secondarily, whether nutrition labels are effective at promoting healthier purchasing if presented alongside ecolabels. Participants (N = 2730) visited an experimental online supermarket platform, and were randomised to see products with (1) environmental impact labels only; (2) nutrition (NutriScore) labels only; (3) both environmental and nutrition labels; (4) no labels. Linear regressions compared the mean environmental impact scores (EIS; primary outcome) and health scores of products in participants' shopping baskets across each condition. Compared to control (no labels) there were significant reductions in the EIS when environmental impact labels were presented: Alone (-1.3, 95%CI: -2.3 to -0.4) or With nutrition labels (-2.0, 95%CI: -2.9 to -1.0), with no evidence of differences in effectiveness between these two conditions. There was no evidence of an impact of nutrition labels on either the EIS or the healthiness of purchases, both when nutrition labels were shown alone and when ecolabels were also present. Environmental impact labels may be effective at encouraging more sustainable purchases alone or when used alongside nutrition labels. This adds to the evidence base on the feasibility and effectiveness of environmental impact labelling as an important measure to change dietary behaviour to improve planetary health.

Effects of environmental impact labels on the sustainability of food purchases: Two randomised controlled trials in an experimental online supermarket.

Providing consumers with product-specific environmental impact information for food products (ecolabels) may promote more sustainable purchasing, needed to meet global environmental targets. Two UK studies investigated the effectiveness of different ecolabels using an experimental online supermarket platform. Study 1 (N = 1051 participants) compared three labels against control (no label), while Study 2 (N = 4979) tested four designs against control. Study 1 found significant reductions in the environmental impact score (EIS) for all labels compared to control (labels presented: values for four environmental indicators [-3.9 percentiles, 95%CIs: -5.2,-2.6]; a composite score [taking values from A to E; -3.9, 95%CIs: -5.2,-2.5]; or both together [-3.2, 95%CIs: -4.5,-1.9]). Study 2 showed significant reductions in EIS compared to control for A-E labels [-2.3, 95%CIs: -3.0,-1.5], coloured globes with A-E scores [-3.2, 95%CIs:-3.9,-2.4], and red globes highlighting 'worse' products [-3.2, 95%CIs:-3.9,-2.5]. There was no evidence that green globes highlighting 'better' products were effective [-0.5, 95%CIs:-1.3,0.2]. Providing ecolabels is a promising intervention to promote the selection of more sustainable products.

Identifying Operational Challenges and Solutions During the COVID-19 Response Among US Public Health Laboratories.

CONTEXT: The ability to diagnose and screen for infection is an important component of the US COVID-19 response and is facilitated by public health laboratories (PHLs). Anecdotal media reports and limited case studies have described some of the challenges faced by PHLs during the pandemic, particularly initial challenges related to developing and deploying tests to PHLs, but there has not been a systematic evaluation of the experience of PHLs during the pandemic. OBJECTIVE: To document challenges and lessons learned experienced by local and state PHLs during the COVID-19 pandemic to support generation of best practices for current and future similar emergencies. DESIGN, SETTING, AND PARTICIPANTS: From February to June 2021, researchers conducted 24 interviews with 68 leaders and staff representing 28 local and state PHLs across 27 states. Thematic analysis of interview content documented operational challenges and any identified solutions or preventive measures used or proposed. MAIN OUTCOME MEASURES: Analysis identified the following themes regarding challenges faced among PHLs: strategic decision making and determining the mandate of the PHL; political interference by jurisdictional leadership; federal mismanagement of the emergency; regulatory challenges; managing partnerships with other laboratories; acquisition of appropriate supplies; insufficient information systems; acquiring and retaining workforce; and difficulty accessing sufficient funding. RESULTS: Within the identified themes, key informants provided further elaboration regarding how PHLs experienced, evaded, or solved these challenges. In addition, PHLs described how challenges evolved throughout the course of the COVID-19 pandemic and made proposals regarding how challenges could be prevented or further addressed in the future by laboratories or other decision makers and stakeholders. CONCLUSIONS: While fellow laboratories and political leadership may gain inspiration from creative solutions employed by PHLs, recognition of long-standing gaps related to funding, laboratory workforce, and consideration of laboratory needs in preparedness policies must be addressed for future large-scale outbreaks.

Retrospective identification of key activities in Uganda's preparedness measures related to the 2018-2020 EVD outbreak in eastern DRC utilizing a framework evaluation tool.

Uganda has engaged in numerous capacity building activities related to outbreak preparedness over the last two decades and initiated additional just-in-time preparedness activities after the declaration of the 2018-2020 Ebola Virus Disease (EVD) outbreak in eastern Democratic Republic of Congo (DRC). When Uganda faced importation events related to the DRC outbreak in June-August 2019, the country's ability to prevent sustained in-country transmission was attributed to these long-term investments in preparedness. In order to help prepare countries for similar future scenarios, this analysis reviewed evidence from Uganda's response to the June-August 2019 importation events to identify preparedness activities and capacities that may have enabled Uganda to identify and isolate infected individuals or otherwise prevent further transmission. Content from 143 grey literature documents gathered via targeted and systematic searches from June 6, 2019 to October 29, 2019 and six interviews of key informants were utilized to inform a framework evaluation tool developed for this study. A conceptual framework of Uganda's preparedness activities was developed and evaluated against timelines of Uganda's response activities to the June-August 2019 EVD importation events based on the applicability of a preparedness activity to a response activity and the contribution of the said response activity to the prevention or interruption of transmission. Preparedness activities related to coordination, health facility preparation, case referral and management, laboratory testing and specimen transport, logistics and resource mobilization, and safe and dignified burials yielded consistent success across both importation events while point of entry screening was successful in one importation event but not another according to the framework evaluation tool. Countries facing similar threats should consider investing in these preparedness areas. Future analyses should validate and expand on the use of the framework evaluation tool.

The Impact of Environmental Sustainability Labels on Willingness-to-Pay for Foods: A Systematic Review and Meta-Analysis of Discrete Choice Experiments.

Food production is a major contributor to environmental damage. More environmentally sustainable foods could incur higher costs for consumers. In this review, we explore whether consumers are willing to pay (WTP) more for foods with environmental sustainability labels ('ecolabels'). Six electronic databases were searched for experiments on consumers' willingness to pay for ecolabelled food. Monetary values were converted to Purchasing Power Parity dollars and adjusted for country-specific inflation. Studies were meta-analysed and effect sizes with confidence intervals were calculated for the whole sample and for pre-specified subgroups defined as meat-dairy, seafood, and fruits-vegetables-nuts. Meta-regressions tested the role of label attributes and demographic characteristics on participants' WTP. Forty-three discrete choice experiments (DCEs) with 41,777 participants were eligible for inclusion. Thirty-five DCEs (n = 35,725) had usable data for the meta-analysis. Participants were willing to pay a premium of 3.79 PPP$/kg (95%CI 2.7, 4.89, p ≤ 0.001) for ecolabelled foods. WTP was higher for organic labels compared to other labels. Women and people with lower levels of education expressed higher WTP. Ecolabels may increase consumers' willingness to pay more for environmentally sustainable products and could be part of a strategy to encourage a transition to more sustainable diets.

The Effects of Environmental Sustainability Labels on Selection, Purchase, and Consumption of Food and Drink Products: A Systematic Review.

This review assessed the effects of environmental labels on consumers' demand for more sustainable food products. Six electronic databases were searched for experimental studies of ecolabels and food choices. We followed standard Cochrane methods and results were synthesized using vote counting. Fifty-six studies (N = 42,768 participants, 76 interventions) were included. Outcomes comprised selection (n = 14), purchase (n = 40) and consumption (n = 2). The ecolabel was presented as text (n = 36), logo (n = 13) or combination (n = 27). Message types included: organic (n = 25), environmentally sustainable (n = 27), greenhouse gas emissions (n = 17), and assorted "other" message types (n = 7). Ecolabels were tested in actual (n = 15) and hypothetical (n = 41) environments. Thirty-nine studies received an unclear or high RoB rating. Sixty comparisons favored the intervention and 16 favored control. Ecolabeling with a variety of messages and formats was associated with the selection and purchase of more sustainable food products.

Associations between number of siblings, birth order, eating rate and adiposity in children and adults.

Eating quickly is associated with eating larger amounts at mealtimes and faster eaters tend to have a higher BMI. Evidence suggests that sibling structure influences the development of childhood eating behaviours. We hypothesized that number of siblings and birth order might play a role in the development of eating rate. In two UK studies, children in Bristol (n = 132; Study 1) and adults and children in London (adults n = 552, children n = 256; Study 2) reported their eating rate, number of siblings, and birth order. A BMI measurement was obtained and in Study 2 waist circumference was recorded. Ordered logistic regression was used to examine effects of sibling structure on eating rate and linear regression assessed effects of eating rate on BMI. Faster eating was associated with higher BMI and a larger waist, in children and adults (ps < .01). In Study 1, first-born children were twice as likely to eat faster compared to children who were not first-born (P < .04). In Study 2, only-child adults reported eating slower than adults who were not first-born (P < .003). Additionally, higher number of siblings was associated with faster eating rate in children from Bristol (P < .05), but not in children from London. London adults without siblings ate slower than those with two or more (P = .01), but having one sibling was associated with eating faster than having two or more (P = .01). These findings reveal how birth order and number of siblings might influence eating rate. Exploring these relationships through direct observation would be beneficial in future studies.

An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations.

INTRODUCTION: Nine events have been assessed for potential declaration of a Public Health Emergency of International Concern (PHEIC). A PHEIC is defined as an extraordinary event that constitutes a public health risk to other states through international spread and requires a coordinated international response. The WHO Director-General convenes Emergency Committees (ECs) to provide their advice on whether an event constitutes a PHEIC. The EC rationales have been criticised for being non-transparent and contradictory to the International Health Regulations (IHR). This first comprehensive analysis of EC rationale provides recommendations to increase clarity of EC decisions which will strengthen the IHR and WHO's legitimacy in future outbreaks. METHODS: 66 EC statements were reviewed from nine public health outbreaks of influenza A, Middle East respiratory syndrome coronavirus, polio, Ebola virus disease, Zika, yellow fever and coronavirus disease-2019. Statements were analysed to determine which of the three IHR criteria were noted as contributing towards the EC's justification on whether to declare a PHEIC and what language was used to explain the decision. RESULTS: Interpretation of the criteria were often vague and applied inconsistently. ECs often failed to describe and justify which criteria had been satisfied. DISCUSSION: Guidelines must be developed for the standardised interpretation of IHR core criteria. The ECs must clearly identify and justify which criteria have contributed to their rationale for or against PHEIC declaration. CONCLUSION: Striving for more consistency and transparency in EC justifications would benefit future deliberations and provide more understanding and support for the process.

A study to assess a novel automated electrocardiogram technology in screening for atrial fibrillation.

INTRODUCTION: Atrial fibrillation is often asymptomatic and un-diagnosed in the community resulting in an increased risk of heart failure and stroke to those patients. We evaluated the effectiveness, tolerability, and accuracy of a novel six-channel electrocardiogram digital-health screening device, the RhythmPad, for the detection of atrial fibrillation. METHODS: Seven hundred and fifty-two participants attending the cardiology department were recruited. Two recordings were taken-a six-lead electrocardiogram using the RhythmPad device and a standard 12-lead electrocardiogram. Recorded traces were analyzed by two blinded cardiologists. The computer-generated automated diagnostic reports from both systems were also compared. Post-participation feedback was obtained from study participants using a three-part questionnaire. RESULTS: The sensitivity of the six-lead electrocardiogram compared to the 12-lead electrocardiogram, analyzed by two blinded cardiologists, for the detection of normal sinus rhythm was 95.9%, with a specificity of 97.2%. The sensitivity for the detection of atrial fibrillation using the six-lead ECG was 93.4%, with specificity 96.8%. The six-lead automated diagnostic report had a sensitivity and specificity of 97.5% and 98.6%, respectively, for correctly diagnosing normal sinus rhythm. For the correct diagnosis of atrial fibrillation, the six-lead automated diagnostic report had a sensitivity and specificity of 95.4% and 98.8%, respectively. A total of 95.4% of participants found RhythmPad to be comfortable, with only 0.5% preferring the 12-lead ECG device in comparison to six-lead ECG acquisitions. CONCLUSION: The RhythmPad digital health device and its automated diagnostic report were highly accurate in detecting atrial fibrillation when compared to a standard 12-lead electrocardiogram.

Breaking the fast: Meal patterns and beliefs about healthy eating style are associated with adherence to intermittent fasting diets.

Many believe that eating three meals each day is healthy and that skipping meals can be detrimental. What remains unclear is whether this belief undermines attempts to restrict energy intake by skipping meals. In an online survey, participants (N = 312) with experience of intermittent fasting (IF) reported their beliefs about healthy meal and snack frequency, as well as their non-fasting-dasy and fasting-day eating patterns. They also reported their level of concern with fasting-day meal patterns and their concern to generate fullness when selecting foods. Individuals currently following an IF diet (Current-IF dieters) and those who had previously attempted an IF diet but were non-adherent (Former-IF dieters) took part. Former-IF dieters were more likely to believe that it is healthy to eat three meals a day, punctuated by several snacks. On fasting-days, Former-IF dieters were also more likely to eat breakfast, a mid-morning snack, lunch, and a mid-afternoon snack whereas Current-IF dieters tended to save their eating for dinner and a late evening snack. Former-IF dieters were also more likely to be concerned about the negative consequences of missing a meal, to eat in anticipation of future hunger, and to prioritise fullness over taste when selecting foods. These findings reveal how beliefs about a healthy eating style can play an important role in shaping dietary patterns. Interventions aimed at modifying beliefs about healthy meal patterns may promote IF diet adherence.

Individual variability in preference for energy-dense foods fails to predict child BMI percentile.

Many studies show that higher dietary energy density is associated with greater body weight. Here we explored two propositions: i) that child BMI percentile is associated with individual differences in children's relative preference for energy-dense foods, ii) that child BMI percentile is associated with the same individual differences between their parents. Child-parent dyads were recruited from a local interactive science center in Bristol (UK). Using computerized tasks, participants ranked their preference and rated their liking for a range of snack foods that varied in energy density. Children (aged 3-14years, N=110) and parents completed the tasks for themselves. Parents also completed two further tasks in which they ranked the foods in the order that they would prioritize for their child, and again, in the order that they thought their child would choose. Children preferred (t(109)=3.91, p<0.001) and better liked the taste of (t(109)=3.28, p=0.001) higher energy-dense foods, and parents correctly estimated this outcome (t(109)=7.18, p<0.001). Conversely, lower energy-dense foods were preferred (t(109)=-4.63, p<0.001), better liked (t(109)=-2.75, p=0.007) and served (t(109)=-15.06, p<0.001) by parents. However, we found no evidence that child BMI percentile was associated with child or parent preference for, or liking of, energy-dense foods. Therefore, we suggest that the observed relationship between dietary energy density and body weight is not explained by individual differences in preference for energy density.

Large Portions Encourage the Selection of Palatable Rather Than Filling Foods.

BACKGROUND: Portion size is an important driver of larger meals. However, effects on food choice remain unclear. OBJECTIVE: Our aim was to identify how portion size influences the effect of palatability and expected satiety on choice. METHODS: In Study 1, adult participants (n = 24, 87.5% women) evaluated the palatability and expected satiety of 5 lunchtime meals and ranked them in order of preference. Separate ranks were elicited for equicaloric portions from 100 to 800 kcal (100-kcal steps). In Study 2, adult participants (n = 24, 75% women) evaluated 9 meals and ranked 100-600 kcal portions in 3 contexts (scenarios), believing that 1) the next meal would be at 1900, 2) they would receive only a bite of one food, and 3) a favorite dish would be offered immediately afterwards. Regression analysis was used to quantify predictors of choice. RESULTS: In Study 1, the extent to which expected satiety and palatability predicted choice was highly dependent on portion size (P < 0.001). With smaller portions, expected satiety was a positive predictor, playing a role equal to palatability (100-kcal portions: expected satiety, ß: 0.42; palatability, ß: 0.46). With larger portions, palatability was a strong predictor (600-kcal portions: ß: 0.53), and expected satiety was a poor or negative predictor (600-kcal portions: ß: -0.42). In Study 2, this pattern was moderated by context (P = 0.024). Results from scenario 1 replicated Study 1. However, expected satiety was a poor predictor in both scenario 2 (expected satiety was irrelevant) and scenario 3 (satiety was guaranteed), and palatability was the primary driver of choice across all portions. CONCLUSIONS: In adults, expected satiety influences food choice, but only when small equicaloric portions are compared. Larger portions not only promote the consumption of larger meals, but they encourage the adoption of food choice strategies motivated solely by palatability.

Identifying individual, cultural and asthma-related risk and protective factors associated with resilient asthma outcomes in urban children and families.

OBJECTIVE: The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families. METHODS: Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6-13 years and their primary caregivers were included. RESULTS: Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks. CONCLUSIONS: This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.

Differences in Environmental Control and Asthma Outcomes Among Urban Latino, African American, and Non-Latino White Families.

Latino and African American children with asthma are at increased risk for asthma morbidity compared with non-Latino White children. Environmental control (ie, environmental exposures and family strategies to control them) may contribute to greater asthma morbidity for ethnic minority children living in urban environments. This study examined ethnic differences in a semi-structured assessment of environmental control, associations between environmental control and asthma outcomes (asthma control, functional limitation, and emergency department [ED] use), and ethnic differences in environmental triggers in a sample of urban Latino, African American, and non-Latino White families. One hundred thirty-three children (6-13 years of age) and their caregivers completed demographic questionnaires, measures of asthma control and morbidity, and a semi-structured interview assessing environmental control. Reported environmental control differed significantly by ethnicity (P<0.05), with Latino families reporting higher levels of environmental control. Reported environmental control was significantly associated with asthma control (P<0.017) and functional limitation (P<0.017). Reported environmental control and ED use were significantly associated in Latino families (P<0.05). Non-Latino White and African American families reported more secondhand smoke exposure than Latino families (P<0.001). Latino families reported more optimal home environmental control than other ethnic groups. Substantial ethnic differences in asthma triggers suggest that observed ethnic disparities in asthma may be due, at least in part, to differences in the home environment.